Healthcare Provider Details

I. General information

NPI: 1073911087
Provider Name (Legal Business Name): LORENZEN LUCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 03/11/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 B ST
LIVINGSTON CA
95334-9593
US

IV. Provider business mailing address

600 B ST BLDG A
LIVINGSTON CA
95334-9593
US

V. Phone/Fax

Practice location:
  • Phone: 209-850-3500
  • Fax:
Mailing address:
  • Phone: 209-850-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09585
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54129
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: